Lake County

Public Health Assessment and Wellness

Houston AIM

State: TX
Type: Model Practice
Year: 2013

ABSTRACT:

The Houston Department of Health and Human Services (HDHHS) is the public health agency for the city of Houston, with a 2010 census population of 2,099,451. Houston is racially and ethnically diverse. Residents are 25.6% white (non-Hispanic): 43.8% Hispanic, 23.7% black, 6.0% Asian, and 1% other. Houston is also a large city, with 579 square miles of land area.

The HDHHS Assessment, Intervention and Mobilization (AIM) reaches out to targeted communities to engage stakeholders, gather information about the community, disseminate information, link clients with services, build community capacity, and enhance the skills and readiness of HDHHS staff. Over time, the practice has been refined to align public health functions with community concerns and impacts.

• In the Assessment phase, HDHHS determines needs and resources by compiling a community profile, conducting surveys, and interviewing local leaders and key community members. • During the Intervention phase, HDHHS identifies and engages community stakeholders; sends teams into the community to go door-to-door to disseminate and collect information; links clients to service providers; and provides resources, such as food baskets, to those in need of immediate assistance. • The Mobilization phase builds community capacity to make improvements, such as implementing neighborhood action teams, clean-ups, home repair programs, Neighborhood Protection Corps, and other functions.

The initial impetus for the AIM projects came from the Public Health Preparedness (PHP) sector of HDHHS. The PHP team was looking into ways to:

The Houston Department of Health and Human Services (HDHHS) is the public health agency for the city of Houston, with a 2010 census population of 2,099,451. Houston is racially and ethnically diverse. Residents are 25.6% white (non-Hispanic): 43.8% Hispanic, 23.7% black, 6.0% Asian, and 1% other. Houston is also a large city, with 579 square miles of land area.
The HDHHS Assessment, Intervention and Mobilization (AIM) reaches out to targeted communities to engage stakeholders, gather information about the community, disseminate information, link clients with services, build community capacity, and enhance the skills and readiness of HDHHS staff. Over time, the practice has been refined to align public health functions with community concerns and impacts.
• In the Assessment phase, HDHHS determines needs and resources by compiling a community profile, conducting surveys, and interviewing local leaders and key community members. • During the Intervention phase, HDHHS identifies and engages community stakeholders; sends teams into the community to go door-to-door to disseminate and collect information; links clients to service providers; and provides resources, such as food baskets, to those in need of immediate assistance. • The Mobilization phase builds community capacity to make improvements, such as implementing neighborhood action teams, clean-ups, home repair programs, Neighborhood Protection Corps, and other functions.
The initial impetus for the AIM projects came from the Public Health Preparedness (PHP) sector of HDHHS. The PHP team was looking into ways to:
1. Provide “new perspective” statistical information on community health status and needs 2. Strengthen the HDHHS safety net response to identified community needs 3. Develop a practical application to enhance National Incident management System (NIMS) training
As the AIM effort developed, it was designed to bring community members, HDHHS and other city departments, and community organizations to a common table to:
A. Identify community issues and assets B. Mobilize community partnerships and resources to address identified issues C. Assess individual household health needs and provide referrals and other resources to address these needs D. Improve the ability of HDHHS and partners to respond to disaster events
These goals have been met and refined. The commitment and cooperative efforts of HDHHS and partners are key to the success.
In September 2006, HDHHS conducted the first AIM project in the Clinton Park/Tri Community Super Neighborhood, one of 88 Super Neighborhoods designated by the city of Houston Planning Department that make up the jurisdiction of Houston. Super Neighborhoods typically have a population of approximately 25,000 and contain roughly 8,000 households. Each AIM project sends teams into the targeted Super Neighborhood to contact each household and provide selected health-related information appropriate for that community. The teams speak with residents when they are home to assess current health needs and provide referrals/resources, and distribute brochures and other materials for all households.
The targeted Super Neighborhoods were chosen based on:
1. High levels of health-related risk factors, such as poverty and minority populations 2. Documented high rates of health disparities
To implement the AIM projects, a planning team begins work 3-6 months before the scheduled event with key community partners, such as the Houston Police Department Neighborhood Protection team. The AIM initiative is organized in the format of the National Incident Command System (NIMS) promoted by the U.S. Department of Homeland Security and crucial to the HDHHS local disaster response.
Preparation and implementation for AIM is performed by the following core sections:
• Planning. Responsible for coordination and oversight of the following planning functions: data collection, community engagement, resource assessment and management• Operations. Responsible for coordination and oversight of planning and implementation of: Community Touch, Service Response, Health Education, and Service Delivery • Logistics. Responsible for providing logistical support including facilities, supplies, food, ground transportation, communication, and for managing the employee care unit • Finance and Administration. Responsible for documenting project costs, maintaining project timesheets, procurement of supplies, producing cost analyses and reports • External Partners. Responsible for securing external resources, engaging partners to participate and documenting partner involvement • Volunteer Team. Responsible for recruiting and placing volunteers • Training. Responsible for developing and implementing training modules • Internal Communications and Public Information. Responsible for developing and releasing information about the project to the public, media, etc.; developing materials for project promotion and keeping employees informed • Safety Officer. Plans for and monitors safety and security of staff
The next AIM project is scheduled for the spring of 2013. The AIM model is scalable and adaptable for use by other agencies and LHDs.

ResponsivenessThe AIM projects are designed to assess health needs and also provide resources such as information, short-term urgent issue response, and connection to longer-term supports. AIM serves to address a wide range of public health issues in targeted Super Neighborhoods, including:
Health Care
• Access to care (i.e. medical home) • Chronic disease • Co-existing conditions • Symptoms associated with environmental hazards • Communicable diseases (TB, STDs) • Environmental concerns • Maternal and child health • Nutrition • Immunizations • Others as identified by the community
Well-Being
• Parks and recreation • Crime • Safety • Gangs • Mental health • Housing • Education needs • Socioeconomic disparities • Mobilization • Others as identified by the community
Numerous methods are used to determine the key public health concerns of each targeted community. These include:
Compilation of Community Profile The Assessment and Analysis unit of the Planning Team compiles a community profile of key Super Neighborhood health indicators using data from vital statistics, hospital discharges, reportable disease surveillance, the U.S. census and various other data sources. The profile is used by the planning committee to determine key health issues each community.
Asset Mapping The Planning Team collects information about the existing assets in the community, and potential sites for AIM staging areas.
Community Engagement Through the AIM process, the Planning Team, Community Engagement Team, and Assessment/Analysis Team meet with community leaders and residents in order to gather information and resources to help guide the AIM project. Community meetings discuss the strengths, assets and challenges of their community, and the actions and resources that could be brought into play to make the community a healthier and safer place to live.
Health Events and Survey In some communities, HDHHS hosts or participates in a Health Fair or other event where residents receive health screenings and health information. In addition, opinion surveys are conducted throughout the event to assess community concerns.
Community Assessment Survey The Assessment team conducts in-depth assessment with a randomly chosen sample of community residents to evaluate local concerns about access to care, safety, environmental health, personal health status, access to healthy food, disaster preparedness, and maternal and child health.
Focus Group Assessment The Assessment Team holds focus group discussions to assess concerns related to health, housing, safety and crime, economic opportunities, and education.
Community Tour A community car caravan drives through the neighborhood to tour key aspects of the neighborhood and identify environmental health issues, followed by a community meeting.
Community Touch The Community Touch component of AIM includes door-to-door distribution of information, discussion with those residents who are home and willing to meet with the surveyors, assessment of residents’ emergent needs, a walkability survey to document the ease and/or barriers of walking in the community, and a field observations log.The AIM projects address the above public health issues through:
Assessment The assessment data described above is provided to the HDHHS teams, community partners and the local community residents, and is used to set priorities and guide public health interventions and community mobilization efforts.
Intervention The Community Touch phase provides educational and referral materials to each household, including a referral guide and a calendar with information specific to the Super Neighborhood. The teams assemble approximately 7,000 “Touch” bags, which are then given to residents or left at their door.
The packets contain information on a wide variety of topics such as: a community resource book, local emergency numbers, information on senior services, materials to help households prepare for emergency, library information, child safety seat use, STD and TB info, WIC guidelines and offices, and much more.
As a part of the Touch phase, residents are asked about current health needs. Approximately 25% of households have answered the door and spoken with the Touch Team members. And about 25% of those residents reported urgent unmet needs for food, shelter, clothing, elder services, counseling, medical services or other needs. These persons complete a Referral and Link form which is provided to the Service Response Team that provides brief, solution-focused interventions of food, referrals to local agencies, and other methods of assistance.
HIV/STD testing and counseling is provided at each AIM site by HDHHS mobile vans.
Mobilization HDHHS begins community mobilization work several months prior to the Community Touch part of the AIM project, and continues afterward. Community members learn about their community’s health issues, often decide to volunteer for the AIM Intervention phase, and then participate in the following efforts to mobilize their communities to improve health and safety concerns.
With the help of HDHHS, most communities have developed ongoing efforts to address concerns identified as a part of the AIM process. Many have developed action teams in areas such as Crime and Safety, Education, Housing, and Economic Empowerment. The project addresses the following CDC Winnable Battles: Global Immunizations HIV in the U.S. Nutrition, Physical Activity, and Obesity
Innovation The AIM projects are a creative use of existing tools and practices.
Initial AIM efforts were based on the National Incident Management System (NIMS) Incident Command Structure (ICS) developed by the U.S. Department of Homeland Security, Federal Emergency Management Agency (FEMA). The NIMS structure built upon methods used by the U.S. Coast Guard and National Fire Service to respond to sea and fire disasters. The ICS structure allowed the Coast Guard and Fire Service to easily mesh recruits from various local, state and national resources into one coordinated command system. FEMA has incorporated these principles into training for local emergency response, with a structure that can be adapted to a wide range of situations such as floods, hurricanes, hazardous materials accidents. Local health departments with Emergency Preparedness components are also trained to utilize the NIMS and ICS systems. More information about NIMS, ICS and FEMA can be found at http://www.fema.gov. The AIM process is creative in that it does not depend on a disaster in order to mobilize the teams, but serves as a public health intervention to assess and assist low income communities with high health disparities. In addition, the effort does improve the department’s ability to respond effectively to a potential local disaster.
The AIM projects did vastly improve the department’s response to recent hurricanes in Houston and nearby communities, as food and water were distributed, temporary shelters were established, health status was monitored, and more. Key source of evidence-based strategies used to develop the AIM process were: 1. The Healthy Community Toolkit at www.healthycommunities.org 2. The NACCHO MAPP Toolkit 3. The Community Change model developed by Tyler Norris, particularly his publication Facilitating Community Change at www.tylernorris.com 4. The ACHI (Association for Community Health Improvement) at www.communityhealth.org for resource ideas to create healthy communities and other concepts used by local hospitals to invest in community healthThe practice is a creative use of an existing tool or practice?Initial ideas for AIM came from Public Health Preparedness and utilized National Incident Management System guidelines, which includes Law Enforcement Patrol Teams (Strike Teams) to respond to immediate needs of the population following a disaster. The Strike Team door-to-door assessment was expanded beyond law enforcement and disaster response for assessment of health-related concerns for individuals and the community.
To develop AIM, HDHHS staff members from different parts of the organization met to create plans that would address multiple needs. Key members of this team and their priorities were:
• Public Health Preparedness—improve the department’s disaster response abilities • Community Health Statistics—analyze available health data for local Super Neighborhoods and gather additional health information using scientifically sound methodology • Human Services—improve the department’s responsiveness to community health needs • Community Engagement—involve each Super Neighborhood in a mobilization process that would improve the department’s relationship with the neighborhood as well as educate and motivate the community to create teams to improve their health status
This team brought these different perspectives together to develop a comprehensive model for AIM to address their various goals in a way that would create an action plan for change in the targeted communities. A literature review and personal conversations with public health professionals across the country show AIM process as a new and creative method. HDHHS has not found any other health departments using this method to work with communities. If fact, other health departments have begun to approach HDHHS to request training in the AIM process.
The department has incorporated a number of tools and practices into the AIM process. In addition to the resources listed above (Healthy Community Toolkit, NACCHO MAPP Toolkit, Facilitating Community Change, ACHI), the HDHHS Community Health Planning, Evaluation and Research (CHPER) Division of Planning, Evaluation and Program Development has incorporated the following validated assessment tools, among others:
1. The SF-8 Health Survey to measure quality of life. This tool was previously used in the Medical Outcomes Study (MOS) and recommended for use in population surveys. It has been extensively used and has strong psychometric properties (validity and reliability). More information is available at the International Quality of Life Assessment website at www.iqola.com.
2. ADL 2 item measure, to measure Activities of Daily Living among the elderly.
3. BRFSS (Behavioral Risk Factor Surveillance System) for measures on access to care and chronic disease prevalence, available at http://www.cdc.gov/brfss.
4. Birth outcomes questions from CDC's PRAMS (Pregnancy Risk Assessment Monitoring System) www.cdc.gov/prams.
5. Adult-Youth Engagement Survey questions from Search Institute, http://www.search-institute.org.
Additional tools/resources include: census data, the Guide to Community Preventive Services website at http://www.thecommunityguide.org/index.html, and mortality data at the Super Neighborhood level, which is available upon request from the Texas Department of State Health Services. The AIM process as an adaption of the National Incident Management System (NIMS) is not a part of the NACCHO Toolbox. However, HDHHS is developing a curriculum for training partners in the AIM process that could be adapted for the NACCHO Toolbox.Local health departments use many types of assessment and intervention to address public health concerns. This AIM model combines many of these into a comprehensive and personal approach to each targeted community, and integrates this with NIMS disaster response principles and structures to provide assessment, intervention and mobilization in communities in response to public health concerns. An increasing number of local health departments are equipping their workforces with NIMS training.
The AIM model provides a method for experiential learning beyond table top exercises so Local health departments use many types of assessment and intervention to address public health concerns. This AIM model combines many of these into a comprehensive and personal approach to each targeted community, and integrates this with NIMS disaster response principles and structures to provide assessment, intervention and mobilization in communities in response to public health concerns. An increasing number of local health departments are equipping their workforces with NIMS training. The AIM model provides a method for experiential learning beyond table top exercises so that staff members get practical experience and provide a direct benefit to communities in greatest need.

Local Health Department and Community Collaboration The primary stakeholders for AIM include HDHHS and other city of Houston departments, residents of the targeted Super Neighborhood, community resources (especially faith, civic, academic and community-based organizations), and service groups such as the Houston Food Bank and the Harris County Area Agency on Aging.
Generally 20 community stakeholder groups form action teams to open their facilities to the AIM teams as base sites, serve as locations for food distribution, and otherwise facilitate AIM efforts.In designing and implementing the AIM projects, HDHHS works in roles defined in the HDHHS Strategic Plan, including:
• Catalyst - bring HDHHS and partner resources together to carry out AIM projects, from planning to implementation. Under direction of the HDHHS AIM Incident Commander, Incident Command staff identifies and assigns HDHHS employees to specific roles following National Incident Management System (NIMS) guidelines. Branches plan the functions, including mapping the community into manageable sections for the Strike Teams; preparing the Operations component for boots on the ground canvassing during the Touch phase; ensuring that supplies and equipment are available as needed; and accounting for expenditures and costs. • Facilitator - lead community/civic, government, and organizational collaboration meetings while building the capacity of natural community leaders to continue the mobilizing process for sustainable long-term change. • Assessor - develop instruments to identify health and human service issues impacting residents and canvassing the community to determine those issues of greatest concern. • Evaluator – gather and quantify information to better inform the department’s strategic direction to address public health issues in that community, and measure community levels of engagement and awareness of health impacts. • Advocate - assist community members in identifying and harnessing public and private resources to address current and emerging issues.
Members of and organizations in the target community are responsible for:
• Assisting HDHHS in recruitment of additional volunteers in preparation for the various AIM phases. • Providing respite locations for AIM Touch teams; mobilizing neighborhood assets and institutions. • Assisting in identifying issues negatively impacting the community; helping to define health. • Forming action teams to continue long-term mobilization work after the assessment and intervention phases have been completed.
Stakeholders and Partners
Stakeholders and partners are intensively involved in the planning and implementation of the process. HDHHS takes the initial lead in organizing meetings, educating stakeholders and partners about the AIM process, and conveying the goals and objectives of the project. Community stakeholders are engaged prior to AIM, provide feedback on the process, and volunteer to carry out important AIM functions. For example, each AIM Touch phase will utilize 14 teams to visit households. To support these teams, local groups such as churches will open their facilities as a staging site for the teams report on progress, keep records, eat lunch, etc. They might also serve as a food/clothing distribution center. And following AIM Touch, they would be actively involved in forming Action Teams to mobilize to solve neighborhood problems.
Another group of partners is engaged for the Service Response component of AIM. These partners are organizations that can step in to help meet the health needs that are identified during the Touch phase. This group includes the Houston Food Bank, Houston Fire Department, some churches, Gulf Coast Community Services, etc. They participate in the planning and execution of the Service Response functions.HDHHS has frequently collaborated with other City, organizational and community shareholders to accomplish public health goals.
AIM-related collaborative relationships with city of Houston departments include:
Houston Police Department provides a police presence in the target community throughout the AIM Touch Phase and is prepared to act as necessary. Additionally, the HPD Differential Response Team is responsible for enforcing ordinances related to the unlawful parking of vehicles in communities.
Houston Public Works and Engineering Department works with HDHHS to identify community infrastructure issues such as street repairs, possible causes of street flooding, right of way maintenance, overgrown grass and weeds, etc.
Houston Solid Waste Management Department works with AIM action teams on community cleanups and educates community members on what classes of trash/debris are picked up and when.
Houston Department of Neighborhoods provides enforcement ability for violation of City ordinances and deed restrictions in the target community and assists with cutting weeded lots and addressing abandoned houses/buildings in the community.
The Houston Bureau of Animal Regulation and Care canvasses each AIM target community to identify and contain loose dogs prior to Touch Teams walking door to door to assess community members’ needs.
Houston Parks and Recreation Department has provided secondary staging areas when located in or near AIM Super Neighborhoods.
HDHHS also relies on other community-based organizations to assist in meeting Touch Phase goals and needs.
Churches, apartment complexes and other community organizations and institutions volunteer to serve as respite locations for Touch Teams, meeting locations for AIM community meetings, and distribution sites for AIM-related events and activities.
Community-based organizations such as Gulf Coast Community Services Association, the Houston Food Bank and Target Hunger have become consistent AIM partners that assist in meeting rental assistance, food and other human service needs in the targeted community. Civic organizations and community members become the volunteers responsible for keeping AIM moving forward through mobilization of the community after the Assessment and Intervention phases have been completed.
These members collectively identify issues affecting the community and form the Action Teams responsible for addressing them.
Lessons learned include:
• Use experience gained from past AIMS to determine staffing and collaborative partners needed and when. Staff and partners tend to become disengaged if not utilized immediately after being activated. If they do not see the value in engagement it will be more difficult to recruit then for future projects. • Have a clearly defined action plan and develop contingencies for weather-related conditions during the Touch Phase. Staff and volunteers need to be confident that planners have considered their needs. • State up front what is being asked of collaborating partners. If they are to be responsible for providing services at no cost to either AIM or the community they will need to have good estimates of the level of need anticipated. If this is unclear, then collaborative partners will be hesitant to join in future projects as trust will be diminished. • Set realistic goals and timelines for each AIM phase and assure that they are aligned with the goals of collaborative partners where necessary. If mutual goals are met there is a greater likelihood that an ongoing partnership will be established. • Ensure that community members are included in each phase of the project and that their voices are heard throughout planning and execution. The goal of long-term mobilization is to foster a truly community-led initiative that will be sustained by the community members with partners aligned to provide the services that they normally provide to assist the community long-term. If there is not community buy-in, then the effort will not be sustained. • Identify and celebrate early wins. This is essential in establishing credibility and motivating both community and organizational partners to continue the project.
Implementation StrategyObjective 1: Approximately one time per year, HDHHS will conduct an AIM project in a targeted community with high health disparities, using the NIMS structure.
1. Define project area, scope and dates2. Develop maps 3. Assign project staff to NIMS chart roles, delineate job actions4. Assign staff for Touch, Intervention, and Assessment Phases5. Visit community, assess hazards and facilities 6. Obtain supplies, equipment, and services7. Provide orientation and training for team 8. Establish dress code, time and attendance procedures 9. Inform media and community about Touch10. Track resources11. Assemble community touch packets12. Recruit and train volunteers13. Deploy Touch Phase strike teams14. Evaluation Touch through after action reporting15. Develop final report and share with staff and stakeholders
Objective 2: The annual AIM project will mobilize community partnerships and resources to enhance the capacity of health and human services in the community to broaden HDHHS’ service reach.
16. Identify and recruit stakeholders and partners17. Hold pre-AIM community meetings 18. Produce community demographic and health profile19. Obtain community feedback on local assets and issues, and project scope 20. Report to community and stakeholders on findings and process (e.g. community profile, scope of inquiry, issues of concern, service area maps, dates, processes, etc.)21. Determine the resources partners will bring to AIM22. Involve partner organizations and community members in AIM activities23. Support continuing community mobilization efforts in the community
Objective 3: The annual AIM project will conduct community assessments, visit 95% of households in the targeted community, talk with residents when possible about their health needs, and will respond with service response referrals.
24. Develop and test assessment tools25. Communicate to community about assessment plans26. Identify and train survey teams27. Conduct survey and focus groups/interviews28. Analyze survey data and write summary assessment report29. Present findings and recommendations to HDHHS staff and community stakeholders30. Train HDHHS staff and partner staff to provide service response 31. Follow up on community Touch referrals32. Evaluate team process and project results33. Recommend improvements for the next AIM
The Planning Phase: This activity initially required six months to assign the NIMS Incident Command Structure, develop the assessment, and plan logistics and operations. As the department became more experienced in conducting the AIM, the planning phase decreased to two months.
AIM Touch Phase: This part of the project has also decreased. Initially, the teams needed two full days and two half days to complete visits to approximately 7,000 households. In 2012, the teams visited 6,863 households in two full days and one half day.
AIM Service Response: The teams responding to households that completed Referral and Link forms requesting various types of immediate assistance initially needed two months beyond the completion of AIM Touch to complete their services. In 2012, Service Response for 725 households was finished in two weeks.
AIM Community Assessment: Timing for the assessment has varied, based on the extent and type of assessment. Key informant interviews and focus groups may require 1-2 months to develop the plans and assessment tools, another 1-3 months to conduct the data collection, and a final 1-2 months to complete the analysis and reporting.
AIM Community Engagement/Mobilization: Meeting with key community members typically begins three months prior to the AIM Touch phase and continues on for several months following to assist the community in establishing their mobilization efforts.
Steps to develop the AIM process have included:
• Defining the AIM process and engaging management in adopting the model• Defining guidelines for choosing Super Neighborhoods for the AIM • Defining guidelines for choosing and assigning staff, and for managing their other job duties while they are out in the field• Training staff members in the NIMS Incident Command Structure and roles• Developing job descriptions for each role in AIM• Adopting collaborative principles to engage partners in AIM Touch and Service Response• Securing funds and other resources to carry out the AIM projects• Refining methods for serving as a catalyst to engage and mobilize communities to improve community health problems• Establishing sources of volunteers to assist in the process• Evaluating and choosing community health assessment methods• Developing procedures for tracking resources• Developing procedures for time and attendance, attending to employee injuries, providing food and water for employees and volunteers• Planning for transportation for teams• Developing a system for communication, including two-way radios, cell phones, and moving computers to the Incident Command site• Developing a system for obtaining referrals from households with immediate health needs and then responding to those needs• Developing methods for obtaining parcel data and creating maps that the teams use to visit households, and for training the teams to then use the maps effectively• Creating a method for staff feedback on their observations and experiences, in order to improve the methods for the next AIM
Lessons learned included:• The NIMS Incident Command Structure (ICS) is scalable. As staff members have become increasingly familiar with new roles in the ICS structure, HDHHS has begun to use the ICS model for more projects, such as See to Succeed, a week-long event held 6-7 times each year, which brings low income children who need eyeglasses to a central site where volunteer optometrists provide exams and glasses are made with donated frames. • Don’t try to do two AIM projects in one year! This simply stretches resources too far.• Have an end-of-day hotwash meeting at the end of each AIM. This allows staff members to discuss the high and low points of their experiences. Many observations have been implemented into plans for the following AIM project. • To effect sustainable community change, the HDHHS team needs to invest time and resources in community engagement early in the AIM process, and maintain a community presence following AIM Touch until the effort “sticks” and the community teams and plans for improvement are well underway. • Staffing patterns can be staggered. Not all staff assigned to AIM need to report at the same time. Some positions, such as Service Response, will not be needed until the Touch teams have been in the field for at least several hours. • Once staff members become familiar with the Incident Command Structure, and with working in the field in AIM projects, training can be reduced. Just-in-time training the day of the event can then be sufficient for the front line team members.• Selection of the Incident Command center and the secondary staging sites that are used as bases for the 13 Touch teams need to be spread out enough to cover the area, but also close enough for frequent communication. • Food is a major concern in the communities we visited; many residents expressed food insecurity. Once we bring a food basket and help to alleviate their anxieties about food, even for a day, they seem better able to step back and plan for solutions for the problems in their lives.
Costs for each AIM project are broken down into three areas.
Supplies: Averages $45,000Includes backpacks, T Shirts with the AIM logo for team members, printing of the educational materials and referral forms, rain ponchos, office supplies, food, ice, water bottles, binders, security, boxes, clip boards, etc.
Transportation: Averages $30,000Includes rental of minivans, gasoline, cargo vans, sedans for use by the teams during the AIM project.
Personnel: Averages $150,000 (includes planning time and also participation in the AIM Touch Phase)Staff members are assigned to AIM as a part of their duties as employees of HDHHS, and volunteers come from many groups and the local community. Therefore, these costs are not direct expenses, but are estimated as a part of the final AIM report.
Note: Recent AIM projects have become less costly as the department has become more efficient in carrying out the tasks.

Goal: To enhance the Department’s ability to respond to disasters and community health needs in neighborhoods with high levels of health disparities.
Objective 1: Approximately once per year, HDHHS will conduct an AIM project in a targeted community with high health disparities. The department will mobilize approximately 25% of the Department and use the NIMS structure, to assess and respond to health issues in an increasingly efficient manner. 1. Performance Measures: a. Frequency of AIM projectsb. Number of staff mobilized using the NIMS structurec. Duration of project activitiesd. Process and outcome evaluation
2. Data Sources: a. Summary reports of planning and implementation activitiesb. Sign in sheets and staff participation reportsc. NIMS structure organization charts and reportsd. Evaluations -- University of Texas School of Public Health, after action hotwash evaluations by staff
3. Evaluation Resultsa. The department has undertaken nine AIM projects since the fall of 2006, an average of 1.5 projects each yearb. The AIM projects have become more efficient. The Planning phase has decreased from 6 months to 2-3 months. The Touch phase decreased from 3 days to 2.5 days. Service Response decreased from 8 weeks to 2 weeks. Staff assigned decreased from 22 Strike Teams to 14 Teams. c. The department has utilized the ICS structure for each AIM project and has implemented ICS for an increasing number of other projects as well. d. A 2007 evaluation of two Touch phases was completed by UT School of Public Health interns through a survey of HDHHS employees during the Sunnyside and Independence Heights Super Neighborhood AIM events. Ninety-seven employees completed the survey. Recommendations from the evaluation are summarized below.
Organization: Improve training so participants better understand project goals, daily schedule, and available resources for households. Assign more staff for end of day wrap-up.
Communications: Provide staff with greater advance notice prior to AIM. Offer staff opportunities for feedback, and give them information about program accomplishments.
Teamwork: Many appreciated the opportunity to meet new co-workers. Everyone worked as a team, regardless of their usual role in the Health Department. If possible, give employees a choice in participation. Offer more opportunities for employees to engage in project planning and understand the benefits of the program to improve project support. Ensure enough t-shirts and other supplies for all.
Assessing and Meeting Needs: The needs of the community were more severe than many employees anticipated, and seeing the community’s needs first hand offered a new perspective. Teach team members strategies for developing rapport with residents. Shorten the referral survey and improve clarity of questions. Hold debriefing sessions for team members at the end of the day.
Referrals: More training regarding available services. Involve more agencies in referrals and ensure they are able to provide assistance. Leaving referral information on doors seemed less effective than providing information face-to-face, especially since some residents have poor reading skills. Have food available for persons with immediate needs.
Health and Safety: Most participants reported that they felt safe, while others were concerned about barking dogs, hostile homes, and walking in streets without sidewalks. Coordinate the project with the Houston Police Department and animal control. Implement AIM during cooler months and ensure plenty of water for participants.
Mobilizing in an Emergency: Participants reported they were better prepared for an emergency, although more training is needed. Recommend that HDHHS continue providing team-building activities in order to maintain a cohesive workforce that can provide an optimum response in an emergency.
A 2010 evaluation done with HDHHS employees found that 87% said they better understood the community and 92% said that AIM helped them identify their roles and functions in the ICS structure.
4. Feedback: Evaluation is provided to the AIM and HDHHS leadership teams. Those in supervisory positions are advised of feedback as each new AIM project begins, in order to incorporate lessons learned into the next project. The AIM Incident Command staff has incorporated nearly all of the recommendations above, with good results. Each AIM project now has an end-of-day hotwash meeting for participants to evaluate “What Went Well” and “What Needs Improvement.” Over time, the feedback has changed. Employees now say that the project is better organized, the food is good, they have the supplies they need and they appreciate working directly with residents. Some have called this experience the highlight of their year’s work. Feedback now centers on how to be more effective, such as “be sure to put the phone and address on the referral forms” or comments about the experience, such as “the mayor’s visit went well.”
Objective 2: The annual AIM project will mobilize community partnerships and resources to enhance the capacity of health and human services in the community to broaden HDHHS’ service reach.1. Performance Measuresa. Length of time to resolve urgent issues identified in Service Responseb. Number and type of partner agencies aligned to receive referralsc. Community level mobilization efforts (with HDHHS as the catalyst)d. Community partners’ assessments of their experiences
2. Data Sourcesa. AIM project recordsb. Records and comments of community partnersc. Community sign-in sheets, agendas, meeting minutes, action plansd. Partner surveys, evaluation conducted by the University of Texas School of Public Health
3. Evaluation Resultsa. Length of time to resolve urgent issues identified in Service Response decreased from two months (2007) to two weeks (2012).b. Number and type of partner agencies that received referrals varied from 13 in Sunnyside (2007) to five at South Park (2012). Partner agencies decreased in number, but increased in efficiency and effectiveness of services.c. Community level mobilization efforts. Community mobilization increased through the years. In 2006, the project was known as AI (Assessment and Intervention), and efforts centered on informing the community about the project and engaging them during the assessment and Touch phases. The “M” for Mobilization came into being in 2007, with an increased emphasis on community involvement in taking action to improve health issues in their neighborhood. Currently, community mobilization begins 3-4 months before the Touch phase and continues on for several months afterward, until the community has understood the assessment information, chosen leaders and priorities, and developed action teams and a mobilization plan for community improvements.
d. In 2007, the University of Texas School of Public Health interns surveyed five community partners through a telephone survey to evaluate their experiences with the AIM projects. Four partners had participated in the Sunnyside AIM and one in Independence Heights AIM. These partners, often pastors/churches or other community centers, served as contacts for their area and opened their facilities for HDHHS employees and volunteers throughout the Touch phase. These partners said that AIM was very effective at disseminating information on the resources that were available to members of the community and educating them on how to access these resources, and were especially enthusiastic about the face-to-face interaction with members of the community. Four of five partners reported that they would be very likely to participate with HDHHS on a community project in the future; the other responded as being somewhat likely to participate. Partners suggested that they would like more data on the needs and demographics of the community and more involvement in the planning. They also commented that earlier involvement could have used the partners more in reaching out the community in preparation and throughout the project, and that partners could help in needs assessment prior to AIM. Some also noted that they would like to receive some of the AIM memorabilia.
4. FeedbackFeedback on partner evaluation was provided to the community and also to the HDHHS Executive Team and the HDHHS AIM Leadership Teams. The feedback was incorporated into future AIM events, with resulting increases in community participation and engagement. Houston communities and Houston City Council members are now approaching HDHHS to ask that we do an AIM project in their communities!
Objective 3: The annual AIM project will conduct community assessments, visit 95% of households in the targeted community, talk with residents when possible about their health needs, and will respond with service response referrals and community mobilization efforts. Community leaders and residents will show increasing awareness of community health issues, resources, and methods to mobilize their community to improve health conditions. 1. Performance Measuresa. Community assessments and profiles developed through the AIM projectsb. Number of households visited in targeted communitiesc. Community awareness of local health issues, resources, and public health effortsd. Individual awareness of resources, as provided to household residents
2. Data Sourcesa. Community assessment reports and profilesb. Reports from each AIM project about the number of households contactedc. Community meetings minutes, PowerPoint presentations, handouts, Action Plansd. Feedback from community members about information and referral sources
3. Evaluation Resultsa. Community assessments and profiles: A brief community profile was completed in 2006 using health data available at the Super Neighborhood level. By 2007, the community profile had expanded to measures of 20 health indicators with community assets and resources. The 2007 assessment also included a survey of 581 households, to assess, access to health care, health behaviors, quality of life, chronic health conditions, and family support systems. A comprehensive community profile at the Super Neighborhood level has been developed for each following AIM project, and includes including key health measures, and community resources and assets, and particular health and safety issues of concern for that neighborhood. A summary report is created following each AIM project, and contains the profile and assessment methods and results.
b. Number of households visited in targeted communities: The AIM projects plan to visit every household in the target area. Maps are created to show each household according to parcels and addresses, and teams are assigned to visit each household. The teams are able to visit more than 95% of households. They knock on doors if they are able, will interview residents who answer about their health needs, and will leave a packet of health information. If they reach a barrier, such as loose dogs in a fenced yard, they will leave information on the gate.
c. Community awareness of local health issues, resources, and public health efforts: Community mobilization efforts begin with presentations about the AIM project and their own community’s health measures, demographics, assets, resources, and health issues. Each AIM project has records of the community meetings, stakeholders, community participants, presentations, handouts and mobilization activities. Community members’ increased awareness of key health issues, resources and public health efforts can be seen in their evaluation of the assessment data, setting of priorities, and development of Action Teams. For example, as a part of AIM mobilization efforts in 2012, the South Park community created Action Teams for Crime (12 members), Education (8 members), Health (14 members) and Infrastructure (24 members).
d. Individual awareness of resources, as provided to household residents: The evaluation of this increased awareness has come through the contacts made by the Touch Team members, who report that most household interviews provide resource information that is new to residents. Findings from seven focus groups held during the 2010 Acres Homes AIM project noted that many were not aware of resources that were available to assist residents with health concerns such as nutrition, safety, access to care, parks and recreation, education and health education, environmental health, general health, communication, crime, mental health, jobs and housing. These groups served both to assess individual awareness of resources, and to provide residents with resource information.
4. Feedback is provided to all HDHHS AIM participants, to interested partners, and to community stakeholders. As a result of feedback information, the AIM Mobilization efforts have increased, to ensure that communities not only receive information on health concerns and resources, but that they move into taking action to improve the awareness and conditions in their own communities.

HDHHS has been conducting AIM projects on an annual basis since 2006, and is committed to the process as an important public health function. The Mayor participates in the AIM projects, and City Council members have begun to ask for the next AIM project to be held in their jurisdiction. Community partners, such the Houston Food Bank, the Houston Fire Department, Harris County Hospital District, and Gulf Coast Community Services Association have participated repeatedly in AIM projects.
In addition, HDHHS is committed to a yearly AIM project as a part of our Public Health Preparedness effort to remain in top readiness for response in the event of local disaster.
As others have learned of the AIM projects, HDHHS has received requests for training from communities and other public health departments. HDHHS is developing training tools that will be used initially for a project in Houston’s Third Ward in the fall of 2012. This training will show members of the community and other Third Ward stakeholders how to conduct an AIM project. As a part of this training, the new teams will visit approximately 500 households in Third Ward. Each expansion of the AIM project adds to the sustainability.
Sustainability is also supported in the ability of HDHHS and partners to become increasingly efficient in the AIM projects. As efficiency increases, and fewer resources are needed, sustainability is enhanced.AIM is becoming increasingly sustainable over time, as more partners and city departments participate and see the value in the training and the services provided. The Houston Police Department, Solid Waste Management Department, Fire Department, and Department of Neighborhoods have become reliable partners in the AIM process. They bring staff and other resources to the projects. For example, the Fire Department installs smoke alarms in AIM households that express interest. These resources help to leverage the AIM scope and the resources that HDHHS can provide.
Community partners have also provided leverage. A food supply network is key to the success of AIM interventions, and groups including the Houston Food Bank, Target Hunger, and churches that are part of a food pantry system have come together to provide immediate and on-going food resources for AIM communities. Other partners have provided rental and utility assistance, resources for cleaning up trash, service referrals for seniors, and prescription cards, among others.